Do not PASS any melanoma without diagnosis: a new simplified dermoscopic algorithm.

INTRODUCTION: Dermoscopic algorithms for melanoma diagnosis could be time-expending, and their reliability in daily practice lower than expected. OBJECTIVE: To propose a simplified dermoscopic algorithm for melanoma diagnosis. MATERIAL AND METHODS: A multicenter retrospective analysis of 1,120 dermoscopic images of atypical melanocytic tumors (320 melanomas and 800 non-melanomas) was performed. An algorithm based on polychromia, asymmetry in colors or structures, and some melanoma-specific structures was designed. Univariate and multivariate logistic regression analysis was calculated to estimate the coefficients of each potential predictor for melanoma diagnosis. A score was developed based on the dermoscopic evaluations performed by four experts blinded to histological diagnosis. RESULTS: Most melanomas had ≥3 colors (280; 84.5%), asymmetry in colors or structures (289; 90.3%), and at least one melanoma-specific structure (316; 98.7%). PASS score ≥3 had a 91.9% sensibility, 87% specificity, and 88.4% diagnostic accuracy for melanoma. PASS algorithm showed an area under the curve (AUC) of 0.947 (95% CI 0.935-0.959). LIMITATIONS: This study was retrospective. A comparison between the performances of different dermoscopic algorithms is difficult because of their designs. CONCLUSION: PASS algorithm showed a very good diagnostic accuracy, independently of the observers' experience, and it seems easier to perform than previous dermoscopic algorithms.

Association between the clinical and demographic characteristics of patients undergoing cataract surgery and their prevalence of conjunctival bacteria.

PURPOSE: To identify characteristics of patients undergoing cataract surgery associated with pathogenic and antibiotic-resistant conjunctival bacteria. SETTING: Spanish tertiary hospital. DESIGN: Retrospective cross-sectional study. METHODS: Records of consecutive patients undergoing cataract surgery between July 2005 and September 2014, contained data on patient characteristics and conjunctival bacteria systematically identified with preoperative tests and anesthetic evaluation. A multivariate logistic regression associated 12 bacterial groups with every category of 17 characteristics. Odds ratio (OR), 95% CIs expressed colonization risk. RESULTS: In 14883 patients, categories associated with pathogenic bacteria were age older than 79 years with nonfermentative gram-negative bacilli (NFGNB) (OR 1.74, 1.12-2.71), enterococci (OR 1.90, 1.36-2.65), Enterobacteriaceae (OR 2.17, 1.65-2.87), and Staphylococcus aureus (OR 1.37, 1.16-1.62); obesity with S aureus (OR 1.52, 1.30-1.78), enterococci (OR 1.99, 1.47-2.68), and Enterobacteriaceae (OR 2.17, 1.70-2.77); dacryocystorhinostomy history with S aureus (OR 1.90, 1.48-2.44), Haemophilus spp. (OR 2.06, 1.37-3.11), Streptococcus pneumoniae (OR 3.14, 2.14-4.62), NFGNB (OR 2.23, 1.28-3.88), and enterococci (OR 1.80, 1.16-1.81); diabetes with S aureus (OR 1.27, 1.13-1.44), enterococci (OR 1.49, 1.19-1.87), and Enterobacteriaceae (OR 1.27, 1.04-1.54); smoking habit with Enterobacteriaceae (OR 2.11, 1.56-2.86); autumn with NFGNB (OR 2.0, 1.35-3.0); hot weather with S aureus (OR 1.23, 1.03-1.47); and lung, renal, and some heart insufficiencies with S aureus. Other staphylococci, highly antibiotic-resistant, were associated with old age, obesity, and hot weather. CONCLUSIONS: Old age, obesity, diabetes, dacryocystorhinostomy history, smoking habit, and autumn and summer seasons increased the prevalence of enterococci, staphylococci, Enterobacteriaceae, and/or NFGNB. Obesity and humid-warm weather are key for choosing a cataract surgery prophylaxis.

Influence of Comorbidities on the Survival of COPD Patients According to Phenotypes.

Background: Chronic obstructive pulmonary disease (COPD) usually occurs alongside other conditions. Few studies on comorbidities have taken into account the phenotypes of COPD patients. The objective of this study is to evaluate the prevalence of comorbidities included in the Charlson index and their influence on the survival of patients with COPD, taking phenotypes into account. Methods: An observational study was conducted on a group of 273 patients who had COPD and underwent spirometry in the first half of 2011, with a median prospective follow-up period of 68.15 months. The survival of these patients was analyzed according to the presence of various comorbidities. Results: Of the 273 patients, 93 (34.1%) died within the follow-up period. An increased presence of chronic ischemic heart disease (CIHD), chronic heart failure (CHF), chronic kidney disease (CKD), and malignancy was found in deceased patients. All of these conditions shorten the survival of COPD patients globally; however, when considering phenotypes, only CHF influences the exacerbator with chronic bronchitis phenotype, CKD influences the non-exacerbator phenotype, and malignancy influences the positive bronchodilator test (BDT) and exacerbator with chronic bronchitis phenotypes. In the multivariate model, advanced age (hazard ratio, HR: 1.05; p=0.001), CHF (HR: 1.74; p=0.030), and the presence of malignancy (HR: 1.78; p=0.010) were observed as independent mortality risk factors. Conclusion: The survival is shorter in the presence of CIHD in overall COPD patients and also CHF, CKD, and malignancy for certain phenotypes. It is important to pay attention to these comorbidities in the comprehensive care of COPD patients.

Prognostic relevance of early AKI according to pRIFLE criteria in children undergoing cardiac surgery.

BACKGROUND: Acute renal injury increases risk of death after cardiac surgery. The objective of the study was to evaluate the ability of the pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria to characterize the development of postoperative renal damage in children after cardiopulmonary bypass (CPB) and to evaluate the relationship between the severity of kidney injury and mortality, pediatric intensive care unit (PICU) length of stay, and the duration of mechanical ventilation (MV). METHODS: In this retrospective study including children undergoing CPB surgery during a 3-year period in the PICU of a tertiary hospital, demographic, clinical, surgery-related, and postoperative clinical data were collected. Kidney damage was assessed with pRIFLE criteria. RESULTS: Four hundred and nine patients were included. Early acute kidney injury (AKI) was found in 82 patients (achieving categories Risk 44; Injury 16; Failure 22). Early AKI was associated with younger age (P = 0.010), longer CPB, deep hypothermic circulatory arrest (DHCA) use, ICU stay >12 days, MV >4 days, and death (P < 0.001). Controlling the effect of age, CPB, DHCA use, previous cardiac surgeries, and Risk Adjustment in Congenital Heart Surgery Surgical Severity Score (RACHS-1), early AKI development proved to predict ICU stay >12 days [odds ratio (OR) 3.5; 95% confidence interval (CI) 1.9-6.5, P < 0.001)] and need of MV >4 days (OR 5.1; 95% CI 2.6-10.2, P < 0.001). CONCLUSIONS: Early AKI when evaluated with the pRIFLE criteria can predict prolonged ICU stay, need of prolonged MV, and mortality.

Circulating tumor cells following first chemotherapy cycle: an early and strong predictor of outcome in patients with metastatic breast cancer.

We investigated the prognostic significance of circulating tumor cells (CTCs) determined immediately before the second cycle of chemotherapy in patients with metastatic breast cancer (MBC). The CTC counts were taken at baseline, before the first cycle of chemotherapy (CTC-0), and on day 21 before commencing the second cycle of chemotherapy (CTC-21) in consecutive MBC patients. The study's primary objectives were to analyze relationships between CTC-21 count and overall survival (OS). Based on the current literature, the CTC measurements were dichotomized as 0-4 versus ≥ 5 CTCs. Of 117 patients recruited, 99 were evaluable. Patients with 0-4 CTCs on day 21 had a significantly better OS than those with ≥ 5 CTCs (median OS: 38.5 months vs. 8.7 months). They also had a significantly better progression-free survival (PFS; median: 9.4 months vs. 3.0 months) and clinical benefit rate (77% vs. 44%). The OS of patients whose baseline CTCs were ≥ 5 but dropped to <5 on day 21 was apparently similar to those who had <5 CTCs at baseline. In a Cox regression analysis, CTC-21 was the only independent variable significantly predicting OS and PFS. Our data indicate that CTCs determined immediately before the second cycle of chemotherapy is an early and strong predictor of treatment outcome in MBC patients.

Erythropoiesis-stimulating agents in anaemia due to chronic kidney disease: a cost-minimization analysis.

BACKGROUND: Some publications have shown that equivalent doses of erythropoiesis-stimulating agents (ESA) defined on label differ from those effective in clinical practice. Therefore, real costs could vary from theoretical costs in the treatment of anaemia in chronic kidney disease (CKD). OBJECTIVES: To perform a cost-minimization analysis to establish the economic impact of the principal ESAs used in treating anaemia secondary to CKD in daily practice. SECONDARY OBJECTIVES: to determine patient-month cost based on the erythropoietin resistance index (ERI); to analyze the difference in cost between pre-dialysis and peritoneal dialysis (PD) patients; and to analyze the association between iron deposits and ESA cost. SETTING: This study was carried out at 2 tertiary hospitals in Spain. METHOD: A multicentre cost-minimization analysis was performed in adult outpatients treated with ESAs for anaemia due to CKD. MAIN OUTCOME MEASURE: The primary outcome was the patient-month cost for each ESA. RESULTS: 409 patients were included. Median patient-month cost was: epoetin (103.2 [63.7, 187.8] euros), darbepoetin α (134.4 [67.2, 216.0] euros) and CERA (147.5 [98.3, 196.7] euros). Median patient-month cost according to ERI was: epoetin (1.60 [0.90, 2.60] euros/kg), darbepoetin α (2.01 [0.95, 3.48] euros/kg) and CERA (1.87 [1.33, 3.00] euros/kg). Median patient-month cost in pre-dialysis was 126.0 (73.7, 201.6) euros and in PD 153.0 (100.2, 275.4) euros. Median patient-month cost for patients with TSI < 20% was 147.5 (98.3, 224.9) euros compared to 100.9 (67.2, 196.7) euros which was the cost for patients with IST ≥ 20%. The median patient-month cost for patients with ferritin < 100 mcg/l was 134.4 (85.0, 201.6) euros compared to 100.8 (68.8, 196.7) euros, which was the cost for patients with ferritin ≥ 100 mcg/l (p = 0.242). CONCLUSION: Doses of CERA used in clinical practice are lower than those recommended on label, which directly influences cost and treatment efficiency. Cost stratification based on iron deposits has shown that patients with low TSI or ferritin require higher doses and consequently an associated higher cost. Thus, to guarantee adequate iron levels is essential in the rational use of ESAs.

Influence on effectiveness of early treatment with anti-TNF therapy in rheumatoid arthritis.

PURPOSE: To evaluate the association between starting early treatment with anti-TNF and effectiveness as well as the possibility of applying therapeutic spacing in daily practice in patients with rheumatoid arthritis (RA). METHODS: Observational, retrospective study conducted in two universitary hospitals in Spain. RA patients who received the first anti-TNF (adalimumab: ADA, etanercept: ETN or infliximab: IFX) during the study period (October 2006-2010) were included. Demographic data, time since diagnosis, disease activity (DAS28-ESR) and anti-TNF dosage were analyzed. Therapeutic objective was defined as DAS28 DAS28 < 2.6. Also the response related to criteria of the European League Against Rheumatism (EULAR) was evaluated. Therapeutic spacing was defined as the use of a lower dose or a higher interval according to label doses. The main endpoint was to assess the association between the effectiveness and the moment when the anti-TNF therapy begins. The secondary target was to evaluate the association between RA activity at the beginning of treatment with anti-TNF and dose used. Results. 82 patients were included. The prescription profile was: ADA (48.8%), ETN (31.7%) and IFX (19.5%). 71.4% of patients treated with anti-TNF during the first year since diagnosis, 57.1% of those who started after 1-5 years and 30.6% of patients who started after 5 years were in remission when the study ended. De-escalation strategy was performed in 25.6% of patients: ETN (38.5%), ADA (20.0%) and IFX (18.8%). The patients treated with a higher dose according to label doses were: IFX (81%), ADA, (12.5%) and ETN (7.7%). CONCLUSIONS: Results suggest that early treatment with anti-TNF can achieve a higher percentage of remissions. Therapeutic spacing is established as a strategy that improves the efficiency in those patients in remission, being the ETN the anti-TNF most susceptible for spacing, although a relation between the early beginning with anti-TNF and the used dose was not found.

Development of a compatibility chart for intravenous Y-site drug administration in a pediatric intensive care unit.

Pediatric patients admitted to intensive care units are likely candidates for intravenous drug administration. These patients may sometimes have limited vascular access, so availability of compatibility charts for intravenous Y-site administration may help daily clinical practice. A 2-dimensional table with the 47 intravenous drugs more commonly administered in the authors' pediatric intensive care unit was drawn up based on a review of 4 databases routinely used for checking drug compatibilities. The level of concordance between the various sources used for the review was strong (κ>0.8). However, an awareness of the limitations of each of these databases will help to optimize search results.

[Risk factors for prolonged mechanical ventilation after cardiac surgery in children]. / Factores de riesgo de la ventilación mecánica prolongada de niños con cirugía cardíaca.

OBJECTIVE: To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit (PICU). PATIENTS: 59 children aged between 2 months and 14 years after cardiac surgery. VARIABLES OF INTEREST: We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a stepwise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. RESULTS: Mechanical ventilation lasted more than 3 days in 19 (32%) children and more than 7 days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxide treatment, midazolam perfusion more than 4 microg/kg/min or fentanyl perfusion more than 4 microg/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. CONCLUSIONS: Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children.

Variación de las subpoblaciones de células T segun la progresión clínica e inmunológica en niños infectados verticalmente por HIV-1 / T-cell subsets variation during clinical and immunological progression in vertically HIV-infected children

El objetivo de este trabajo es estudiar las subpoblaciones de células T vírgenes, memoria y activadas en sangre periférica de 65 niños infectados verticalmente por el HIV, considerando su categoría clínica, inmunológica y los valores de carga viral (CV). Todos los niños HIV fueron tratados con terapia antirretroviral (AR) (26 niños con terapia AR combinada y 39 en terapia AR altamente agresiva). Las subpoblaciones de linfocitos T se analizaron por citometría de flujo con marcaje triple y se expresaron en porcentaje. Las células T CD4+ vírgenes (CD45RA+CD62L+) estuvieron disminuidas en niños con bajo porcentaje CD4+, pero no en niños en estadios avanzados de la enfermedad o con CV elevadas. Por el contrario, las células T CD8+ vírgenes estuvieron disminuidas en niños con bajo porcentaje CD4+, en estadio avanzado de la enfermedad y con CV elevadas. Las células T CD4+ y CD8+ de memoria (CD45RO+) y activadas (CD38+, HLA-DR+ y CD38+HLA-DR+) estuvieron elevadas en niños con bajo porcentaje CD4+, en estadio avanzado de la enfermedad y con CV elevadas. Sin embargo, las células CD4+CD38+ estuvieron más elevadas en los niños HIV con CD4+>25 por ciento que en el grupo control (p<0,001) y más disminuidas en los niños con bajo porcentaje CD4+. El porcentaje de células T CD4+ y CD8+ vírgenes y memoria depende del porcentaje CD4+ más que de la categoría clínica o el valor de CV. Nuestros datos indican una asociación entre bajo porcentaje CD4+ y CV elevadas con la expresión elevada de marcadores de activación celular, pero no así en estadios clínicos avanzados, posiblemente debido al tratamiento antirretroviral.